Provider Demographics
NPI:1548237142
Name:JOHNSON, ANDREW IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:JOHNSON
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LOOKER MOUNTAIN TRL
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-3441
Mailing Address - Country:US
Mailing Address - Phone:814-368-7498
Mailing Address - Fax:
Practice Address - Street 1:25 LOOKER MOUNTAIN TRL
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-3441
Practice Address - Country:US
Practice Address - Phone:814-368-7498
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017506L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice